Provider Demographics
NPI:1043864432
Name:MACK, DESTINY LACARA
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:LACARA
Last Name:MACK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11009 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-3498
Mailing Address - Country:US
Mailing Address - Phone:404-831-2098
Mailing Address - Fax:
Practice Address - Street 1:3485 N DESERT DR STE 105
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-5724
Practice Address - Country:US
Practice Address - Phone:678-724-7033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET004155235Z00000X
GASLPA0003962355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant